Provider Demographics
NPI:1821387804
Name:VAN WAGENER, ELLEN CHIFICI (MCD, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:CHIFICI
Last Name:VAN WAGENER
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36515 MANCHAC TRACE AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3223
Mailing Address - Country:US
Mailing Address - Phone:225-333-0685
Mailing Address - Fax:
Practice Address - Street 1:36515 MANCHAC TRACE AVE
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3223
Practice Address - Country:US
Practice Address - Phone:225-333-0685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4776235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist